Mental/Psych Disorders Flashcards
Anxiety - key characteristics
- subjective sense of dread or unease
- most common psychiatric disorder
- comorbidities = depression
Anxiety - exam findings
- first step is to determine if anxiety comes before or after a medical illness or it is because of a med side effect
- evaluate for physical explanation
Anxiety - management
- Buspar (serotonin-receptor antagonist) - for patients with already established dx of anxiety, good for chronic/long-term therapy
- Benzos - very effective short-term, caution in elderly
- refer to psychiatry
Generalized Anxiety Disorder (GAD) - clinical presentation
- many potential presentations
- restless, irritability, difficulty concentrating, muscle tension, sleep disturbances, insomnia, fatigue, SOB, tachycardia, diarrhea, headache
- do thorough H&P: can cause somatic complaints, can be caused by meds
Generalized Anxiety Disorder (GAD) - diagnostics
- to rule out medical illness
- CBC, BMP, TSH, urine, EKG
Generalized Anxiety Disorder (GAD) - screening tools
- GAD-7: 7 questions about mental state over the past week. > 10 = moderate anxiety
- GAD-2
- suicide risk assessment
Generalized Anxiety Disorder (GAD) - diagnostic criteria
- *excessive anxiety and worry, occurring more days than not for at least 6 months
- anxiety/worry associated with 3 of the following: restlessness/ on-edge feeling, easily fatigued, difficulty concentrating, going blank, irritability, muscle tension, sleep disturbances
- not d/t direct effects of substance or general medical condition
- anxiety and symptoms cause significant distress in important areas of functioning
Generalized Anxiety Disorder (GAD) - non-pharm management
- education: avoid stimulants and etoh
- cognitive behavioral therapy
- most effective combo is cognitive behavioral therapy + pharm tx
Generalized Anxiety Disorder (GAD) - pharm management
- *SSRIs (first line), 4-6 weeks for effect, side effects early in tx (headaches, decreased libido), do not stop abruptly, ex: paroxetine (Paxil) and sertraline (Zoloft)
- SNRIs: venlafaxine (Effexor) CAN CAUSE INCREASED BP
- benzos: okay for short-term, may be used with SSRIs/SNRIs until they take effect
Generalized Anxiety Disorder (GAD) - follow-up/referral
- follow up: every 1-2 weeks when adjusting dose, some are on meds indefinitely
- refer to psych when provider feels they don’t have a good handle on patient
Panic Disorder - definition
- presence of recurrent, unpredictable panic attacks, which are distinct episodes of intense fear or discomfort associated with physical symptoms
Panic Disorder - diagnostic criteria
- one month of concern or worry about the attacks or change in behavior r/t them
- attacks have sudden onset (within 10 minutes) and are usually resolving over the course of an hour and occur in unexpected fashion
Panic Disorder - treatment
- goal: decrease frequency of attacks and reduce intensity
- antidepressants: SSRIs (Paxil, sertraline (Zoloft), Celexa, Lexapro
- SSRIs take a while to have effect so may need short-term benzo
Depression - types
- major depressive disorder (MDD): biggest risk factor is personal hx of depression
- dysthymic disorder: when patient has depressive symptoms for 2 years, worse in winter
- Bipolar disorders: typically worse in fall
Depression - who is more likely to be depressed?
- *previous episode of depression
- elderly
- female
- concurrent medical illness or substance abuse
Depression - when to suspect?
- Pain: headaches, chronic complaints of pain
- unexplained GI complaints
- low energy, chronic fatigue
- apathy, irritability, anxiety
- sexual complaints
Depression - physical findings
- poor hygiene, unkempt appearance
- weight gain
- significant constipation or impaction, GI complaints
- slowed body systems
Depression - in men
- thought of as “female disorder”
- more likely to talk about physical symptoms (tired, low performance/sexual desire)
- less likely to show sadness, irritability
- 4x more likely to commit suicide
Depression - screening tools
- 2-item screening tool:
1. in the past month have you felt down, depressed, or hopeless?
2. in the past month have you felt little interest or pleasure in doing things? - PHQ-9: questionnaire that helps determine if pt has mild, moderate, or severe depression
- Beck Depression Inventory
- Geriatric Depression Scale
Depression - management (non-pharm)
- psychotherapy + meds = best combo
- always rule out suicidal ideation (huge risk factor for suicide is previous attempt)
- treat underlying condition first and refer to psych if uncomfortable or too extensive
Depression - management (pharm)
SSRIs -citalopram (Celexa), paroxetine (Paxil), fluoextine (Prozac), sertraline (Zoloft) - *major side effects: headaches (usually initial but will usually fade), sexual dysfunction, serotonin syndrome SNRIs - venlafaxine (Effexor) - do not give with MAOIs - *watch BP! - usually tried when SSRIs fail TCAs - amitriptyline (Elavil) - more side effects - lethal in overdose - need cardiac monitoring MAOIs - tranylcypromine (Parnate) - dietary restriction (Tyramine) - risk of hypertensive crisis after intake of tyramine
Depression - follow-up
- 1 week: suicide risk increases (energy level increase)
- 2 weeks
- monthly
- prescription duration: 6-12 months after remission, longer if multiple disorders or longer hx of depression
Depression - referral
- suicidal or homicidal behavior
- failing therapy after 1-2 months
Major Depression - criteria
KNOW THIS
- occurrence of one major and five or more minor symptoms for 2 weeks
- major: depressed mood or loss of interest or pleasure
- minor: depressed mood most of day, significant weight loss/gain, psychomotor agitation, insomnia, or hypersomnia
Major Depression - most common presenting symptom
- adhedonia (don’t have ability to feel pleasure)
Major Depression - treatment
- psychotherapy + SSRIs
- ECT, TMS, and ketamine infusions are also other less common options
Suicide - characteristics
- 10th leading cause of death in US
- men > women, older white, and live alone
- *70% of suicides see PCP within 6 weeks of suicide
Suicide - clinical features
- *hopelessness (reg flag)
- may or may not state intentions to you
- may start to give away possessions, quit job
- *may appear abruptly peaceful (red flag)
- self-mutilation, making threats, hallucinations/ delusions
Suicide - assessment
- always assess for suicidal ideation, intent, and plan
Suicide - risk acronym
SAD PERSONAS
S - sex A - age D - depressions P - previous attempts E - ethanol abuse R - rational thinking loss S - social support loss O - organized plan N - no spouse A - availability of lethal means S - sickness
Bipolar - characteristics
- episodic shifting between mania and major depression, hypomania, and mixed mood states
- prevention of mood cycling is crucial
- mood fluctuations are chronic and must be present for 2 years before dx can be made
Bipolar - treatment
KNOW THIS
- Lithium (mainstay)
- side effects: GI issues, n/v, polyuria, weight gain, skin eruptions, edema
- need to be checking BMP for GFR and kidney function and lithium levels
- sustained lithium of at least 0.8 is optimal prophylaxis
- also need to be treating their depression (antidepressants)
- refer to psych if needed
Schizophrenia - characteristics
- group of syndromes characterized by “massive disruption” in thinking, mood, and behavior, poor filtering of stimuli
- often has insidious onset in late adolescence and often has poor outcome (progresses from social withdrawal, perceptual distortion, to recurrent delusions and hallucinations)
- multifactorial causes
Schizophrenia - criterira
- positive and negative symptoms for a 1 month period and continued signs for at least 6 months to make dx
- *positive: hallucinations, delusions, formal thought disorder
- *negative: decreased social ability, restricted affect, poverty of speech, anhedonia, decreased emotional expression, impaired concentration, diminished social engagement
- negative symptoms influence poor outcomes and poor response to tx
- dx of exclusion
Schizophrenia - diagnostics
CT/MRI is necessary for 1st episode of any schizophrenia or psychotic episode of unknown cause (rule out brain lesion/tumor)
Schizophrenia - treatment
- Antipsychotic meds
- mainstay
- good at treating positive symptoms
- “Atypicals”: clozapine (can cause agranulocytosis and seizures, WBC count weekly, seizure precautions), risperidone
- “Typicals”: phenothiazines, thioxanthnese, haldol
- full remission takes 6-8 weeks, works in 70% of patients
- side effects: QT PROLONGATION, weight gain, extrapyramidal symptoms, neuroleptic malignant syndrome, tardive dyskinesia
Violence in Acute Care Setting - differentials
- aggression and violence usually symptoms and not a disease
- aggression: depression, schizophrenia, personality disorders, mania, paranoia
- impulse control disorders: physical abuse, pathological intoxication
Violence in Acute Care Setting - warning signs
- if abuser has hx of violence, it is the best predictor they will do it again
- provocative behavior
- angry demeanor
- loud, aggressive speech
- tense posture
- frequently changing body position/pacing
Domestic Violence - symptomatology
- trouble expressing anger
- long-term anger
- passivity in relationships
- feels “marked for life”
- feels “deserving” of abuse
- lack of trust
- dissociation of affect
Domestic Violence - red flag
If abuser has controlling behaviors toward the abused, wants to be in exam room and won’t leave, or patient has unexplained or inconsistent injuries
Domestic Violence - managing victim
- treat as a trauma victim
- assist pt in finding therapeutic relationship
- temporary emergency centers/counseling
- treat medical/psych problems
- be compassionate
- look for scars, bite marks, poorly healed fractures, bruises (esp. on inner aspect of bony), vaginal or anal laceration/wounds, may have significant tachycardia or anxiety (esp. if abuser is around)
- Xray, SANE exam, STI exam, etc.
Grief - stages
Denial, anger, bargaining, depression, acceptance
Grief - uncomplicated grief
- natural human response
- emotional, physical, behavioral, cognitive, spiritual, social aspects
- should be diminished within a 6-18 month time frame
Grief - complicated grief characteristics
- earliest complicated grief should be diagnosed 6 months post-loss and persists > 1 month
- diagnosed if pt cannot carry out ADLs after 3 months
- substantial distress, functional impairment, increased risk for suicide
Grief - who is at risk for altered grief
- PTSD, MDD are often comorbid
- sudden death
- prior experience with loss, chronic stress r/t medical condition, lack of support
Grief - physical findings
- extreme emotional pain
- depression
- physical pain
- anger, loss of control
- may have preoccupation with item/person they lost
- may have suicidal or homicidal thoughts
- depends on stage
Grief - how to manage in acute care?
- evaluate, keep them safe, talk, assess behaviors
- psych referral, psychotherapy
- SSRIs and TCAs are not appropriate for immediate grief
Transgender - role as provider
- always ask what name and pronoun they prefer
- always keep in mind they are still at risk for certain risk factors for their biologic gender
- when no private rooms available, room them according to preferred gender
Transgender - med reconciliation
Testosterone - side effects include elevated BP, polycythemia, worsening lipid panel and glucose
Estrogens and anti-androgens - high risk of thrombosis (SMOKING = HUGE RISK FACTOR), elevation of BP and prolactin, migraines
Powerlessness - role as provider
- incorporate a “patient review” (similar to ROS) to address non-technical aspects of care - basically a “checking-in” with the patient to evaluate their concerns and if they are being addressed
- ask for feedback, incorporate patient’s perceptions and suggestions into care
Serotonin Syndrome - what is it?
- serotonin toxicity
- potentially life threatening
- associated with increased serotonergic activity in CNS (hyper-stimulation/brainstorm of serotonin receptors)
- SSRIs are biggest culprit - even larger risk if they are on multiple SSRIs and/or SNRIs
- most present within 24 hours of addition of new serotonin med, most within 6 hours
Serotonin Syndrome - diagnostics
- dx made on clinical grounds
- labs to rule in/out differentials and monitor complications
Serotonin Syndrome - Hunter Toxicity Criteria Decision Rule
Patient must have taken a serotonin agent and have a respective symptoms/criteria
Serotonin Syndrome - symptomatology
- myoclonus
- agitation, anxiety
- delirium
- abdominal cramping
- sweating
- hyperpyrexia (high fevers)
- HTN
- vomiting
- potentially death
Serotonin Syndrome - mangement
- depends on how severe your patient is
- discontinue all serotonergic agents!
- supportive tx: antipyretics, cooling blanket, etc.
- sedation if necessary, intubation if necessary
- serotonin antagonist (Cyproheptadine) if necessary
- consult medical toxicologist, pharmacy, or poison control
- usually lasts about 24 hours and will usually come back to baseline
Tardive Dyskinesia - what is it?
- serious side effect that may occur with use of certain meds used to treat mental illness
- may appear as repetitive, jerking movements that occur in face, neck, and tongue
- long-term use of meds (TCAs) can cause TD (25% of pts)
- symptoms may persist even after med is stopped
Tardive Dyskinesia - risk factors
- elderly
- female
- DM
Tardive Dyskinesia - treatment
- clonazepam and gingko biloba
- Ingreza (valbenazine) or Austedo (deutetrabenazine)
Neuroleptic Malignant Syndrome (NMS) - what is it?
- life threatening medical emergency
- associated with neuroleptic agents (ex: haldol)
- usually occurs within first 2 weeks of tx
- cause unknown, blocking of dopamine transmission
Neuroleptic Malignant Syndrome (NMS) - criteria
Dx should be suspected with 2 of 4 features: mental status change, rigidity, FEVER, dysautonomia while taking a neuroleptic agent
Neuroleptic Malignant Syndrome (NMS) - labs
- elevated CK (shows muscle damage from rigidity) and elevated leukocytes
Neuroleptic Malignant Syndrome (NMS) - management
- STOP CAUSATIVE AGENT
- supportive care - ABCs, etc.
- lower fever, lower BP
- prevent complications
- *Dantrolene (direct-acting skeletal muscle relaxant)
- recovery is 7-11 days
Delirium - characteristics
- acute disorder of attention with onset hours to days, characterized by confusion, disorientation, and fluctuation over the course of the day
- # 1 cause = infection
- factors that cause delirium include multiple meds, infection, metabolic disorders, electrolyte imbalances, dehydration, urinary retention, fecal impaction, > 60, frailty, visual impairment
Delirium - exam
- complete neuro (special attention to LOC, orientation, focal neuro defecits)
- hearing and visual
- pulm and cardiac exam
- check for signs of infection
- signs of trauma
- MMSE and Geriatric Depression Scale
Delirium - treatment (non-pharm)
- supportive care
- minimize stimuli
- clocks and calendars
- maintain hydration, nutrition, and oxygenation
- bowel and bladder
- keep on day/night schedule
- TREAT UNDERLYING CAUSE
Delirium - Management (pharm)
- Haldol (QTc prolongation risk), Zyprexa, ativan IM
- benzos (ativan) may worsen delirium/dementia (don’t use on elderly)
- oral seroquel, zyprexia, risperidol may be used if patient is lucid
PTSD - characteristics
- complex somatic, affective, cognitive, and behavioral effects of psychosocial trauma
- causes dysfunction of social, interpersonal, and occupations in one’s life
- may feel depersonalized, may be unable to recall certain aspects of the trauma, often have flashbacks, dreams
PTSD - criteria
- must have had some type of exposure that led them to this issue, presence of intrusion of thoughts or symptoms, marked alterations in behavior, duration > 1 month
PTSD - causes
- sexual violence
- interpersonal trauma (ex: loss of loved one)
- interpersonal violence (ex: assault)
- organized violence (ex: refugee)
- combat
- natural disasters
PTSD - screening
20-point questionnaire
PTSD - treatment
- *SSRIs (first line), SNRIs
- tx for 6 months but can be up to 1 year to prevent relapse/reoccurrence
- refer if necessary
Eating Disorders - avoidant/restrictive
- cardinal feature is avoidance or restriction of food intake usually stemming from lack of interest or distaste of food
- associated with weight loss, nutritional deficiency, dependency on nutritional supplements, marked impairment of psychosocial functioning
- functional deficits and developmental delays may be significant if disorder is long-standing unrecognized
Eating Disorders - anorexia nervosa
- restrict caloric intake to a degree their body deviates significantly from age, gender, health, and developmental norms and exhibit fear of gaining weight and association disturbance of body image
- can be very life-threatening
- leukopenia, elevated BUN, metabolic alkosis, hypokalemia, hypothermia, sinus bradycarida, osteoporosis (huge long-term risk)
- patient may report amenorrhea and skin abnormalities (petechiae, dryness)
Eating Disorders - bulimia nervosa
- engage in recurrent and frequent (at least once/month for 3 months) periods of binge eating and then resort to compensatory behaviors such as purging, enemas, laxatives, excessive exercise to avoid weight gain
- fluid and electrolyte abnormalities, cardiac/conduction abnormalities
- be alert for dental erosion and parotid gland enlargement
Eating Disorders - when to hospitalize
KNOW THIS
- hypokalemia or other serious electrolyte imbalances
- syncope
- hypoglycemic coma
- symptomatic bradycardia
- severe hypotension
- dehydration
- seizure
- prolonged QTc
- BMI < 14
- development of suicidal r other psychiatric instability
Eating Disorders - treatment
- *cognitive behvaioral therapy
- antidepressants (SSRIs) for bulimia tx
Decision Making Capacity/Capacity - characteristics
- competent = only judge can decide
- decision-making capacity = healthcare can decide
- minimal mental, cognitive, behavioral ability, trait, or capability that is required for a person to perform a particular legally recognized act or assume legal role
Decision Making Capacity/Capacity - most common reason to question decision making capaicty
- when patient refuses tx
- our job is to explain tx, help them understand tx, alternatives, consequences, and ask why they are refusing
Decision Making Capacity/Capacity - rules to exception
Medical emergencies
- lack of tx will cause permanent injury or death
- individual does not lack capacity to make the decision
- consent has been obtained from appropriate 3rd party
Incompetence (legally-deemed)
Waiver
Therapeutic privilege (disclosure of pt info would cause patient more harm or it is in the best interest of patient)
Crisis Intervention - risk factors
- illness
- lost body part
- lost role (ex: lost child)
- threat of death
- accident
- financial or relationship issues
Crisis Intervention - subjective findings
- may be angry (esp. with healthcare personnel)
- denial
- depression
- anxiety
- slow thought processes
Crisis Intervention - first step
KNOW THIS
- identify your own fears and concerns before you help anyone else with a crisis intervention and keep yourself safe
Crisis Intervention - management
- stabilize self
- listen, encourage coping skills that have worked in the past
- referral - social work, elicit social support
- realistic plan
